It’s no secret that Medicare and other major healthcare payers in the United States continue to make huge strides toward value-based purchasing, moving away from traditional Fee-for-Service (FFS) payments. In fact, this transition has been taking root for more than a decade and has quickened since the passage of the Patient Protection and Affordable Care Act of 2010 (ACA). As a result, the role of the Health Information Professional has been expanding and evolving in some unexpected ways.
Value-based purchasing places unprecedented scrutiny and importance on medical records accurately represent patient data. This data is used in a variety of ways, from differentiating payment amounts, to informing consumers where the “best” services can be received at the facility- or individual provider-level, to positively impacting patient outcomes.
Effects to the bottom line: Probably the most well-known way coding can affect providers is its direct impact to the financial bottom line. This is true under traditional FFS but has become more complex and nuanced under value-based purchasing. In traditional FFS, not accounting for the proper services may cause payment suspension, delays in reimbursement, or additional administrative burden due to third-party medical review. However, in value-based purchasing, these inaccuracies have other ripple effects that are not even recognizable at first. For example, services that contribute data elements to quality measures often require additional data input to fully represent those services. Partially omitting these data points often skews performance results and reimbursements in negative ways.
Effects on patient outcomes: Healthcare today is not a single instance of care within a single provider setting. Instead, value-based purchasing and other advanced payment models (APMs) view service delivery through the lens of population health. As a result, providers are expected to share information from one setting to the next, coordinate care among competitors and execute longitudinal plans of care in which each provider is accountable to only a small component of the overall service(s) provided.
In this new ecosystem of care, an accurate medical record serves as the critical link to patient care and proper reimbursement. When healthcare organizations focus on data validity with respect to medical records, they can make meaningful use of health information, achieving positive patient and financial outcomes.
Effects on public perception: Consumers conduct research before making even mundane purchases. Reading customer reviews on household appliances, vacation destinations, landscapers and other products and services is now a standard practice in many households. As the Centers for Medicare & Medicaid Services (CMS) continues to refine quality measure descriptions into the language of today’s healthcare consumer, it’s reasonable to assume those consumers will increasingly research healthcare provider and facility outcomes and costs. Hospital Compare uses a five-star rating system by combining 57 quality measures, allowing visitors to compare quality of care among more than 4,000 hospitals and identifying areas where hospitals can improve.
Signature Performance’s specialized coding analysts often support community-based and rural hospitals to review and assess Hospital Compare scores. For example, through initial data review of hip and knee replacement scores, Signature identified coding deficiencies that resulted in inaccurate clinical reporting to CMS. To address this issue, Signature developed a provider technical assistance and audit plan that improved coding accuracy and the validity of data reported.
Going forward, healthcare consumers will be armed with information around experience, expected outcomes, and costs. On June 27, 2019 the Trump Administration issued Executive Order 13877, titled “Improving Price and Quality Transparency in American Healthcare to Put Patients First” to require hospitals to publicly post standard charge information, including negotiated rates, for common or shoppable items and services.
What can you do about it: Coding’s role continues to evolve and play a more critical part in capturing information to enhance the care continuum. To prepare coders for success in this new chapter of healthcare focused on data validity, keeping their skills ahead of the curve is critical. Improved coding and clinical documentation increases ability to expedite payments and reimbursements, align with emerging value-based payment models, improve patient outcomes, and support provider reputation management. Signature is working to support providers across the public and private sectors in achieving these goals. To find out more about our support in increasing coding accuracy and improving core quality measures, visit here.
Michelle Swertzic is the VP of Health Solutions & Strategy at Signature Performance Inc., in Omaha NE. Signature Performance is an industry leader in reducing healthcare administration costs for private and public healthcare sectors. Our unmatched experience in serving both the payer and provider side of healthcare financial management allows us to implement innovative solutions for every administrative demand.